SSTI Part 2 Flashcards
What risk factors are there in Diabetic Foot Infection (DFI) ulcer and amputation?
Previous amputation Past foot ulcer Peripheral neuropathy Foot deformity Peripheral vascular disease Visual impairment Diabetic nephropathy Poor glycemic control Cigarette smoking
How do DFI’s present?
Ulcer or wound with swelling and erythema
Absence of pain
Osteomyelitis occurs in 30-40% of cases
Describe mild DFI?
Local infection involving only the subcutaneous tissue, erythema can be present or absent but would be between 0.5 cm and 2 cm around the ulcer
Describe moderate DFI?
Local infection WITH erythema over 2 cm, or involving structures deeper than skin and subcutaneous tissue with NO systemic inflammatory response signs
Describe severe DFI?
Local infection with signs of SIRS, classified as 2 or more of the following:
- Temperature over 38 degrees celsius or less than 36 degrees celsius
- Heart rate over 90
- Respiratory rate over 20 or PaCO2 less than 32
- White blood cell count over 12000 or less than 4000 cells or over 10% immature bands form
How are DFI’s treated?
Empiric:
Mild to moderate with no recent antibiotic use, cover gram + cocci only
Moderate to severe infection: may involve anaerobes/gram negatives so use broad coverage
Empiric MRSA treatment is warranted if there’s a history of MRSA infection or colonization or if local MRSA prevalence is over 30-50%, or if there’s a severe infection
Empiric pseudomonas coverage needed if there’s a high local prevalence, warm climate, or frequent exposure to water
What is osteomyelitis? Describe the 3 stages
Progressive inflammatory destruction of bone tissue due to infection
Acute is less than 2 weeks
Subacute 2-4 weeks
Chronic greater than 4 weeks
How does Osteomyelitis present?
Tenderness over affected area Reduced motion in affected limb Pain Swelling Fever Chills Malaise Nonspecific signs/symptoms
Treatment for osteomyelitis if you have specific culture?
Debridement of necrotic tissue
Culture and sensitivity (superficial culture unreliable)
IV antibiotics for 4-6 weeks
MRSA:
Vancomycin, goal trough 15-20 mcg/mL
Daptomycin 6-8 mg/kg every 24 hours
Ceftaroline 600 mg q8-12h
MSSA:
Oxacillin/Nafcillin 12g/day via continuous infusion
Cefazolin 6 g via continuous infusion
Ceftriaxone 2g IV daily
Empiric treatment for Osteomyelitis?
Empiric gram negative culture: Ceftazidime 2g IV q8h Ertapenem 1g IV q24h Cefepime 6g via continuous IV infusion Piperacillin/Tazo 13.5 g via continuous IV infusion Ciprofloxacin 750 mg BID
Anaerobes: Ertapenem, Piperacillin-tazobactam, clindamycin, metronidazole
Monitoring for Osteomyelitis treatment?
CBC, CMP weekly and PRN
Vancomycin trough weekly and PRN
CPK at baseline at weekly for daptomycin
FP is a 26 year old female presenting to urgent care. FP notes a large, erythematous, tender, and painful abscess on her inner thigh. She reports it started as small red bumps and progressed to its present appearance. No other reported signs or symptoms. PMH: No significant. Allergies: NKDA. Medications: Tums PRN heartburn. SH: College student, lives alone. VS: BP 135/79 mmHg, pulse 65 bpm, respiratory rate 19 bpm, T 98.9oF, Ht 5’2”, Wt 51kg. Physical exam: one large (9 X 7 mm in diameter) abscess on patients inner thigh which is warm and tender to the touch, erythematous, and discharging purulent fluid; skin is somewhat erythematous around the infected site. All other aspects of exam are negative. Local MRSA rate is 35% at this walk in clinic. Assessment: Single large furuncle on the inner thigh requiring treatment. The physician asks for your treatment recommendation.
A: Refer to the ED for IV antibiotics
B: Doxycycline x 7 days, incision and drainage (I&D), wound care
C: Doxycycline x 7 days
D: Incision and drainage (I&D), wound care
D: Incision and drainage (I&D), wound care
Rationale: Answer: d. See slide 21. Mild purulent infection. The patient is not systemically ill and therefore does not require treatment in the ED or IV antibiotics. Because the patient has no risk factors listed on slide 21, systemic antibiotics are not indicated. Because the furuncle is large, I&D is the mainstay of therapy and should not be treated with antibiotics alone. Objective 4.
SS is a 33 year-old male who is diagnosed with a necrotizing skin and soft tissue infection of left upper extremity with confirmed monomicrobial Streptococcus infection. Allergies: NKDA. What is the best recommendation for an antibiotic regimen to be used in conjunction with surgical management?
A: Clindamycin + vancomycin
B: Vancomycin + piperacillin-tazobactam
C: Vancomycin + penicillin G
D: Penicillin G + clindamycin
D: Penicillin G + clindamycin
Rationale: Answer: d. Slide 44 and 45. Objective 4.
PD is a 42 year old female who presents to the ED after being bitten on her hand by a cat. There are significant puncture wounds but no crush injury. Potential puncture of second metacarpophalangeal joint. Vital signs and labs are within normal limits. PMH: hypertension. The physician indicates that the wound does not look clinically infected but would like your recommendation regarding the need for antibiotics. Appropriate wound care has been completed. What is the best recommendation?
A: No antibiotics needed ᅞ
B: Ampicillin/sulbactam (Unasyn) X 14 days ᅞ
C: Amoxicillin/clavulanate (Augmentin) X 14 days ᅚ
D: Amoxicillin/clavulanate (Augmentin) X 5 days
D: Amoxicillin/clavulanate (Augmentin) X 5 days
Rationale: Answer: d. See slides 79. Based on location of puncture wounds antibiotics are indicated. Augmentin is the drug of choice. As there is no infection 3 – 5 days are sufficient for prophylaxis. Patient should monitor closely for development of infection. Objective 4.
